Abstract Objective: To determine differences between men and women in hazardous drinking, heavy cannabis use and hypnosedative use according to educational level and employment status in the economically active population in Spain. Method: Cross-sectional study with data from 2013 Spanish Household Survey on Alcohol and Drugs on individuals aged 25-64 [n = 14,113 (women = 6,171; men = 7,942)]. Dependent variables were hazardous drinking, heavy cannabis use and hypnosedative consumption; the main independent variables were educational level and employment situation. Associations between dependent and independent variables were calculated with Poisson regression models with robust variance. All analyses were stratified by sex. Results: Hazardous drinking and heavy cannabis use were higher in men, while women consumed more hypnosedatives. The lower the educational level, the greater the gender differences in the prevalence of this substances owing to different consumption patterns in men and women. While men with a lower educational level were higher hazardous drinkers [RII = 2.57 (95%CI: 1.75-3.78)] and heavy cannabis users [RII = 3.03 (95%CI: 1.88-4.89)] compared to higher educational level, in women the prevalence was the same. Women with a lower education level and men with a higher education level had higher hypnosedative consumption. Unemployment was associated with increased heavy cannabis use and hypnosedative use in both women and men and with lower hazardous drinking only in women. Conclusions: There are differences between men and women in the use of psychoactive substances that can be explained by the unequal distribution of substance use in them according to educational level. Unemployment was associated with substance use in both men and women.

Abstract Objective: To determine differences between men and women in hazardous drinking, heavy cannabis use and hypnosedative use according to educational level and employment status in the economically active population in Spain. Method: Cross-sectional study with data from 2013 Spanish Household Survey on Alcohol and Drugs on individuals aged 25-64 [n = 14,113 (women = 6,171; men = 7,942)]. Dependent variables were hazardous drinking, heavy cannabis use and hypnosedative consumption; the main independent variables were educational level and employment situation. Associations between dependent and independent variables were calculated with Poisson regression models with robust variance. All analyses were stratified by sex. Results: Hazardous drinking and heavy cannabis use were higher in men, while women consumed more hypnosedatives. The lower the educational level, the greater the gender differences in the prevalence of this substances owing to different consumption patterns in men and women. While men with a lower educational level were higher hazardous drinkers [RII = 2.57 (95%CI: 1.75-3.78)] and heavy cannabis users [RII = 3.03 (95%CI: 1.88-4.89)] compared to higher educational level, in women the prevalence was the same. Women with a lower education level and men with a higher education level had higher hypnosedative consumption. Unemployment was associated with increased heavy cannabis use and hypnosedative use in both women and men and with lower hazardous drinking only in women. Conclusions: There are differences between men and women in the use of psychoactive substances that can be explained by the unequal distribution of substance use in them according to educational level. Unemployment was associated with substance use in both men and women.

Objective: To examine trends in the prevalence of problematic cocaine use in a large city and describe the problems encountered when estimating these trends using capture-recapture techniques based on secondary data Methods: We used clinical data on accident and emergency department episodes at four university hospitals in Barcelona (Spain) between 1999 and 2008 (3 capture periods per year). Users were categorized into two subgroups depending on concomitant heroin use (cocaine plus heroin, cocaine without heroin). Results: The mean age of users was 34 years and 25% were women (2008). The mean number of episodes per user differed between drug subgroups and over time. The estimated total number of cocaine users increased from 6,028 (95% confidence interval [95%CI]: 4,086-9,327) in 1999 to 22,640 (95%CI: 14,001-37,500) in 2006, but decreased thereafter. The prevalence of problematic use of cocaine plus heroin was stable throughout the study. Thus, trends in the prevalence of problematic cocaine use differed depending on concomitant heroin use. Conclusion: Our results are consistent with those provided by health surveys and treatment registries. They also highlight the pitfalls of applying the capture-recapture approach to secondary data, and the need for a better understanding of how information is collected and changes over time.

Objective: To examine trends in the prevalence of problematic cocaine use in a large city and describe the problems encountered when estimating these trends using capture-recapture techniques based on secondary data Methods: We used clinical data on accident and emergency department episodes at four university hospitals in Barcelona (Spain) between 1999 and 2008 (3 capture periods per year). Users were categorized into two subgroups depending on concomitant heroin use (cocaine plus heroin, cocaine without heroin). Results: The mean age of users was 34 years and 25% were women (2008). The mean number of episodes per user differed between drug subgroups and over time. The estimated total number of cocaine users increased from 6,028 (95% confidence interval [95%CI]: 4,086-9,327) in 1999 to 22,640 (95%CI: 14,001-37,500) in 2006, but decreased thereafter. The prevalence of problematic use of cocaine plus heroin was stable throughout the study. Thus, trends in the prevalence of problematic cocaine use differed depending on concomitant heroin use. Conclusion: Our results are consistent with those provided by health surveys and treatment registries. They also highlight the pitfalls of applying the capture-recapture approach to secondary data, and the need for a better understanding of how information is collected and changes over time.

Background: The National Plan for Drugs in Spain (PNSD) fostered the prevention and treatment of illegal drug use disorders, and now also covers alcohol use disorders. The goal of this paper is to estimate the number of persons in specialized treatment because of alcohol in public services. Methods: Review of the key documents of the PNSD, the drug information system of Catalonia, and the Barcelona drug information system. For Catalonia and Barcelona data from 1991 to 2010 are presented. Results: In recent years, there has been more information available for Spain as a whole, of varying validity and comprehensiveness. In Catalonia, the number of reported admissions to treatment for alcohol use disorders has risen: alcohol causes yearly over 40% of all admissions in the drug addiction treatment network; mean age is 44 years, and 23% are women. In Barcelona, admissions to treatment due to alcohol are more than 2.000 each year, relative frequency is 217 by 100.000 residents over 15 years for men and 67 for women. Conclusions: Available data shows that for alcohol, the drug information system needs further development in Spain, solving methodological issues. Available data for Catalonia suggests that the network of drug treatment centres has improved treatment for alcohol use disorders along with that of illegal drugs. This information is relevant, as there is almost no population based treatment data. This information should be completed for other Regional Administrations.

Background: The National Plan for Drugs in Spain (PNSD) fostered the prevention and treatment of illegal drug use disorders, and now also covers alcohol use disorders. The goal of this paper is to estimate the number of persons in specialized treatment because of alcohol in public services. Methods: Review of the key documents of the PNSD, the drug information system of Catalonia, and the Barcelona drug information system. For Catalonia and Barcelona data from 1991 to 2010 are presented. Results: In recent years, there has been more information available for Spain as a whole, of varying validity and comprehensiveness. In Catalonia, the number of reported admissions to treatment for alcohol use disorders has risen: alcohol causes yearly over 40% of all admissions in the drug addiction treatment network; mean age is 44 years, and 23% are women. In Barcelona, admissions to treatment due to alcohol are more than 2.000 each year, relative frequency is 217 by 100.000 residents over 15 years for men and 67 for women. Conclusions: Available data shows that for alcohol, the drug information system needs further development in Spain, solving methodological issues. Available data for Catalonia suggests that the network of drug treatment centres has improved treatment for alcohol use disorders along with that of illegal drugs. This information is relevant, as there is almost no population based treatment data. This information should be completed for other Regional Administrations.

Objectives: Opioid overdose is still the first cause of preventable death among young men in Barcelona. Sound knowledge of opioid overdose prevention is important to avoid complications and deaths. This study aimed to identify the factors associated with limited knowledge of overdose prevention and to assess the possible effect of treatment and overdose prevention training programs on this variable. Methods: From October 2008 to March 2009, current injecting opioid users attending harm reduction centers in Catalonia (Spain) were interviewed. Crude and adjusted prevalence ratios of limited knowledge about overdose prevention were calculated by adjusting Poisson regression models with a robust variance. Results: In this sample, 28.7% of clients had limited knowledge of overdose prevention. Factors associated with limited knowledge were country of origin, never having received treatment for drug dependency, having a low educational level, and never having experienced an overdose. In contrast, treatment at the time of the interview was not associated with a lower prevalence of limited knowledge about overdose prevention. Conclusions: These findings suggest that preventive programs would benefit from accounting for linguistic and educational limitations and from participation in every treatment episode. Comprehensiveness and broad coverage of such programs could help to maximize their impact.

Objectives: Opioid overdose is still the first cause of preventable death among young men in Barcelona. Sound knowledge of opioid overdose prevention is important to avoid complications and deaths. This study aimed to identify the factors associated with limited knowledge of overdose prevention and to assess the possible effect of treatment and overdose prevention training programs on this variable. Methods: From October 2008 to March 2009, current injecting opioid users attending harm reduction centers in Catalonia (Spain) were interviewed. Crude and adjusted prevalence ratios of limited knowledge about overdose prevention were calculated by adjusting Poisson regression models with a robust variance. Results: In this sample, 28.7% of clients had limited knowledge of overdose prevention. Factors associated with limited knowledge were country of origin, never having received treatment for drug dependency, having a low educational level, and never having experienced an overdose. In contrast, treatment at the time of the interview was not associated with a lower prevalence of limited knowledge about overdose prevention. Conclusions: These findings suggest that preventive programs would benefit from accounting for linguistic and educational limitations and from participation in every treatment episode. Comprehensiveness and broad coverage of such programs could help to maximize their impact.

Objective: The use of the Spanish National Death Index (S-NDI) is increasing as it is free and easily accessible. Prompted by unexpected findings when linking two cohorts of patients with the S-NDI, this study was performed to evaluate the quality of mortality data from this source. Methods: Individual records of two cohorts of persons admitted to drug abuse treatment in Barcelona (n=19,974) and Madrid (n=17,557) were linked with the S-NDI and then with the National Statistics Institute (NSI) to assign vital status. The sensitivity and specificity of the S-NDI in relation to the NSI and estimates of mortality with both systems were obtained. Underestimation of mortality by the S-NDI for the same period in the whole of Spain was also calculated. Results: For Madrid, from 1997-2008, independent searches in the S-NDI underestimated mortality by 18.9% compared with the NSI. A subsequent individualized search limited to deaths detected by the NSI but not by the S-NDI reduced underestimation to 13.9%. For Barcelona, underestimation with a combined search (independent plus limited) was 3.3%. From 2001-2002, underestimation with combined searches reached 32.3% in Madrid and 7.3% in Barcelona. Underestimation was also seen in the general Spanish population (1.8% in 1997-2008 and 9.3% in 2001-2002). From 1997-2008, the specificity of independent searches in the S-NDI was 100%, but its sensitivity in Madrid was only 81%. Conclusions: The quality of the S-NDI is good enough for many uses in the health sector, but this index underestimates mortality with substantial spatiotemporal variations. The quality of the S-NDI could be increased by improving its search algorithms, enabling on-line tabulations of the main results, and introducing quality controls and routine evaluations.

Objective: The use of the Spanish National Death Index (S-NDI) is increasing as it is free and easily accessible. Prompted by unexpected findings when linking two cohorts of patients with the S-NDI, this study was performed to evaluate the quality of mortality data from this source. Methods: Individual records of two cohorts of persons admitted to drug abuse treatment in Barcelona (n=19,974) and Madrid (n=17,557) were linked with the S-NDI and then with the National Statistics Institute (NSI) to assign vital status. The sensitivity and specificity of the S-NDI in relation to the NSI and estimates of mortality with both systems were obtained. Underestimation of mortality by the S-NDI for the same period in the whole of Spain was also calculated. Results: For Madrid, from 1997-2008, independent searches in the S-NDI underestimated mortality by 18.9% compared with the NSI. A subsequent individualized search limited to deaths detected by the NSI but not by the S-NDI reduced underestimation to 13.9%. For Barcelona, underestimation with a combined search (independent plus limited) was 3.3%. From 2001-2002, underestimation with combined searches reached 32.3% in Madrid and 7.3% in Barcelona. Underestimation was also seen in the general Spanish population (1.8% in 1997-2008 and 9.3% in 2001-2002). From 1997-2008, the specificity of independent searches in the S-NDI was 100%, but its sensitivity in Madrid was only 81%. Conclusions: The quality of the S-NDI is good enough for many uses in the health sector, but this index underestimates mortality with substantial spatiotemporal variations. The quality of the S-NDI could be increased by improving its search algorithms, enabling on-line tabulations of the main results, and introducing quality controls and routine evaluations.

Background: The Drugs Advice Service (SOD in its Catalan acronym) in Barcelona (Catalonia, Spain) provides an Information and Guidance Program (IGP) for teenagers, and an Alternative Measures Program (AMP) targeting minors fined for consumption / possession of illegal drugs in public spaces. This study describes these programs and compares the profiles of their users. Methods: Cross-sectional descriptive study of 1,010 people discharged from the two SOD programs in 2008-10 after screening for psychiatric disorders and addiction and an extended brief intervention for subjects without pathology. The profiles of the users were compared, and age-specific rates of AMP use were calculated. Results: Cannabis causes 89.9% of entries in the SOD. The proportion of IGP users with high risk criteria for cannabis is 13.3% and with risk for alcohol 11.3%, while in AMP it is 8.9%, and 4%. Criteria for substance dependence or abuse or another psychiatric disorder caused referral of 6% of AMP users and 38% of IGP users. Conclusions: Adolescents in the AMP had a pattern of cannabis use (and often of alcohol) of low or moderate risk, compared to IGP. Beyond the value of the indicated prevention intervention, the programmes facilitate the early detection and referral of problematic substance use and mental disorders in early stages.

Background: The Drugs Advice Service (SOD in its Catalan acronym) in Barcelona (Catalonia, Spain) provides an Information and Guidance Program (IGP) for teenagers, and an Alternative Measures Program (AMP) targeting minors fined for consumption / possession of illegal drugs in public spaces. This study describes these programs and compares the profiles of their users. Methods: Cross-sectional descriptive study of 1,010 people discharged from the two SOD programs in 2008-10 after screening for psychiatric disorders and addiction and an extended brief intervention for subjects without pathology. The profiles of the users were compared, and age-specific rates of AMP use were calculated. Results: Cannabis causes 89.9% of entries in the SOD. The proportion of IGP users with high risk criteria for cannabis is 13.3% and with risk for alcohol 11.3%, while in AMP it is 8.9%, and 4%. Criteria for substance dependence or abuse or another psychiatric disorder caused referral of 6% of AMP users and 38% of IGP users. Conclusions: Adolescents in the AMP had a pattern of cannabis use (and often of alcohol) of low or moderate risk, compared to IGP. Beyond the value of the indicated prevention intervention, the programmes facilitate the early detection and referral of problematic substance use and mental disorders in early stages.

Objectives: To estimate the prevalence of direct and indirect syringe sharing among intravenous drug users (IDUs) attending a harm reduction center in Catalonia (Spain) and to identify factors associated with risk behaviors. Methods: A cross-sectional study was conducted between 2008 and 2009 in harm reduction centers. Behavioral data were collected using anonymous questionnaires administered by trained interviewers. Results: Of the 748 respondents, 31.5% had shared syringes at least once in the previous 6 months and 55.2% reported sharing injection paraphernalia (spoons, water, filters). A higher risk of syringe sharing was found among IDUs who injected daily (OR=1.5), injected cocaine (OR=1.6), had less than half their supply of syringes from a free source (OR=2.5), had an IDU sexual partner (OR=1.8) or who reported indirect sharing (OR=4.1). A higher risk of indirect sharing was found in respondents who had an illegal source of income (OR=1.5), injected daily (OR=1, 5), injected cocaine (OR=1.4), reported sharing syringes (OR=3.9), or who reported a previous overdose (OR=1.5). Conclusions: Despite the widespread use of harm reduction programs in Catalonia, a significant proportion of IDUs continue to practise injection-related risk behaviors. Further reductions in risk behaviors could be achieved by improving access to all sterile injecting equipment, especially among cocaine injectors and IDUs who inject frequently, and by including IDU sexual partners within the current network of harm reduction centers.

Objectives: To estimate the prevalence of direct and indirect syringe sharing among intravenous drug users (IDUs) attending a harm reduction center in Catalonia (Spain) and to identify factors associated with risk behaviors. Methods: A cross-sectional study was conducted between 2008 and 2009 in harm reduction centers. Behavioral data were collected using anonymous questionnaires administered by trained interviewers. Results: Of the 748 respondents, 31.5% had shared syringes at least once in the previous 6 months and 55.2% reported sharing injection paraphernalia (spoons, water, filters). A higher risk of syringe sharing was found among IDUs who injected daily (OR=1.5), injected cocaine (OR=1.6), had less than half their supply of syringes from a free source (OR=2.5), had an IDU sexual partner (OR=1.8) or who reported indirect sharing (OR=4.1). A higher risk of indirect sharing was found in respondents who had an illegal source of income (OR=1.5), injected daily (OR=1, 5), injected cocaine (OR=1.4), reported sharing syringes (OR=3.9), or who reported a previous overdose (OR=1.5). Conclusions: Despite the widespread use of harm reduction programs in Catalonia, a significant proportion of IDUs continue to practise injection-related risk behaviors. Further reductions in risk behaviors could be achieved by improving access to all sterile injecting equipment, especially among cocaine injectors and IDUs who inject frequently, and by including IDU sexual partners within the current network of harm reduction centers.